MS.

JECELI ALVIOLA NOBLEZA, BSN-RN

Critically analyze the nursing implications

of the client with intrapartal complications

SPECIFIC OBJECTIVES

Explain abnormalities that may result in dysfunctional labor.

Describe maternal and fetal risks associated with premature rupture

of the membranes.Analyze factors that increase a womans risk for preterm labor.Explain maternal and fetal problems that may occur if pregnancypersists beyond 42 weeks.Describe common intrapartum emergenciesExplain therapeutic management of each intrapartum complication.Apply the nursing process to care of women with intrapartumcomplications and to their families.

INTRAPARTUM

pertaining to theperiod of labor andbirth.

DYSFUNCTIONAL LABOR

Dysfunctional labor is one that does not

result in normal progress of cervicaleffacement, dilation, and fetal descent.

Dystocia is a general term that describes

any difficult labor or birth.

A dysfunctional labor may

result from problems with:powers of laborthe passengerthe passagethe psyche,or a combination of these.

4 Ps

An operative birth (vacuum extractor or forcepsassisted or cesarean) may be needed if

dysfunctional labor does not resolve or if fetal ormaternal compromise occurs.

Correct cause if it can be identified.

NURSING CAREInterventions related to amniotomyand oxytocin augmentation.Encourage position changes. Anabdominal binder may help direct thefetus toward the mothers pelvis if herabdominal wall is very lax.Ambulation if no contraindication andif acceptable to the woman.Emotional support: Allow her toventilate feelings of discouragement.Explain measures taken to increaseeffectiveness of contractions. Includeher partner/family in emotional supportmeasures because they may haveanxiety that will heighten the womansanxiety.

Promote uterine blood flow: side-lying

position.Promote rest, general comfort, andrelaxation.Pain relief.Emotional support: Accept the realityof the womans pain and frustration.Reassure her that she is not beingchildish.Explain reason for measures to breakabnormal labor patterns and their goal/expected results. Allow her to ventilateher feelings during and after labor.Include partner/family

Ineffective Maternal may result from:Pushing

Use of incorrect pushing techniques or inappropriate

pushing positionsFear of injury because of pain and tearing sensationsfelt by the mother when she pushesDecreased or absent urge to pushMaternal exhaustionAnalgesia or anesthesia that suppresses the womansurge to pushPsychological unreadiness to let go of her baby

Nursing1. Upright positions such ascare:- squatting - add the force of gravity to her efforts.- Semisitting, side-lying, and pushing while sitting onthe toilet are other options.2.

3.

4.

Regional analgesia methods may restrict

possible maternal positions and may alter awomans spontaneous urge to push.Encouraging to push with intermittentcontractions also allows her to maintainadequate pushing effort.Oral or intravenous fluids provide energyfor the strenuous work of second-stagelabor.

McRobert's maneuver

adds gravity to her pushing efforts.

Suprapubic pressure

B.

Suprapubic pressure by an assistant pushes

the fetal anterior shoulder downward todisplace it from above the mothers symphysispubis.Fundal pressure should not be used, becauseit will push the anterior shoulder more firmlyagainst the mothers symphysis.

Higher levels of anxiety and fear during a

observation for signs

of intrauterine infectionand for compromisedfetal oxygenation

Precipitate Laborrapid birth that occurs within 3 hours oflabor onset. There is often an abrupt onset of intensecontractions rather than the more gradualincrease in frequency, duration, andintensity that typifies most spontaneouslabors.

The fetus may suffer direct trauma, such as

intracranial hemorrhage or nerve damage,during a precipitate labor.

The fetus may become hypoxic because

intense contractions with a short relaxationperiod reduce time available for gasexchange in the placenta.

Uterine contractions that may or may not

be painful; the woman may not feelcontractions at all.A sensation that the baby is frequentlyballing up.Cramps similar to menstrual cramps.Constant low backache; intermittent orirregular mild low back pain

contn manifestations

Sensation of pelvic pressure or a feeling that

the baby is pushing down.Pain, discomfort, or pressure in the vulva orthighs.Change or increase in vaginal discharge(increased, watery, bloody).Abdominal cramps with or without diarrhea.A sense of just feeling bad or coming downwith something.

and reduces fetal pressure on the cervix

Hydrating the Woman

been shown to be beneficial for all women.

irritability for some women.

Tocolyticsusually delay preterm birth rather than prevent it.This delay may provide time to allow the use of

corticosteroids to accelerate fetal lung maturity or to

transfer the woman to a facility with a neonatalintensive care unit that is appropriate for the gestationof her fetusFour types of drugs are used for tocolytic therapy: (1) magnesium sulfate, (2) beta-adrenergics, (3) prostaglandin synthesis inhibitors (4) calcium antagonists.

TOCOLYTIC DRUGS

MagnesiumSulfate

used in the management of pregnancy-induced hypertension to

prevent seizures

Beta-Adrenergics Ritodrine (Yutopar) is a beta-adrenergic currently approved by the

U.S. Food and Drug Administration (FDA) to stop preterm

contractions.Terbutaline (Brethine), considered investigational to treat pretermlabor, is the more widely used drug in this class because it has alower cost, longer duration of action between doses, and the abilityto promptly administer a dose by the subcutaneous rather than oralroute if needed (AAP & ACOG, 2002).

ProstaglandinSynthesisInhibitors

Prostaglandins - stimulate uterine contractions, drugs may be used

to inhibit their synthesis. Indomethacin is the drug in this class thatis most often used for tocolysis.

Calcium Blockers Nifedipine (Procardia) is a calcium channel blocker often given forproblems such as chronic hypertension. Calcium is essential formuscle contraction in smooth muscles such as the uterus, soblocking calcium reduces the muscular contraction.

ComplicationsThe mother is at higher risk for postpartuminfection. The newborn is at greater risk for sepsisafter birth, with the most immature preterminfants having the greatest risk for thesystemic infection.

Therapeutic fetus is 35 weeks gestation or moreManagementIf labor does not begin spontaneously, the womanspregnancy is at or near term, and her cervix is favorable,labor induction may be done. If the cervix is not favorable and no infection is present,

induction may be delayed 24 hours or longer to allow

cervical softening and administration of drugs to combatinfection associated with early membrane rupture.If induction is unsuccessful or if infection or other

complications develop, a cesarean birth is most common.

woman is 34 weeks gestation or

earlier:the physician weighs the risks ofinfection against the infants risk forcomplications of prematurity.Ceasarean birth is more common ifdelivery at the earlier gestation isneeded.